Contemporary insights into the epidemiology, impact and treatment of secondary tricuspid regurgitation across the heart failure spectrum

Abstract

Abstract Background Tricuspid regurgitation secondary to heart failure (sTR) is common with considerable impact on survival and hospitalization rates. Currently, insights into epidemiology, impact, and treatment of sTR across the entire heart failure (HF) spectrum are lacking yet are necessary for informed health care decision-making. Purpose To investigate (i) the demographic aspects of sTR overall and according to HF subtype, (ii) the association of sTR with mortality compared to expected survival in the age and sex matched community (iii) differences in subgroups, to identify patients at increased risk of mortality and (iv) to assess treatment demand and utilization for sTR in a unique setting with a population-wide health-care plan and state-of-the-art medical facilities. Methods This population-based study included individual data from 13469 patients with HF and sTR over a 10-year period. Primary outcome measure was long-term mortality. Results Overall, heart failure with preserved ejection fraction (HFpEF) was the most frequent (57%, n = 7733) HF subtype and the burden of comorbidities was high. Severe sTR was present in 1514 patients (11%), most common among patients with reduced EF (HFrEF) (20%, n = 496). Mortality of patients with sTR was higher than expected survival of sex- and age-matched community and independent of HF subtype (moderate sTR: Hazard ratio [HR] 6.32; 95% Confidence Interval [CI] 5.88-6.80, P<0.00, severe sTR: HR 9.04; 95% CI 8.27-9.87, P<0.001). In comparison to HF and no/mild sTR patients, mortality increased for moderate sTR (HR 1.58, 95%CI 1.48-1.69, P<0.001) and for severe sTR (HR 2.19, 95%CI 2.01-2.38, P<0.001). Survival is presented in Figure 1. This effect prevailed after multivariate adjustment and was similar across all HF subtypes (Figure 2). In subgroup analysis severe sTR mortality-risk was more pronounced in younger patients (<70a). Moderate and severe sTR were rarely treated surgically or percutaneously (3%, n = 147), despite availability of state-of-the-art facilities and universal health care. Conclusion sTR is frequent, increasing with age and associated with excess mortality independent of left ventricular ejection fraction. Nevertheless, sTR is rarely treated surgically or percutaneously. With the projected increase in HF prevalence and population ageing the data suggest a major burden for health-care systems, that needs to be adequately addressed. Low-risk transcatheter treatment options may provide a suitable alternative.Figure 1Figure 2